CWA HEALTH CARE REFORM UPDATE: Benefit Limits

The ACA mandates that health insurance policies can no longer have lifetime or annual limits. Does the Act also prohibit dollar amount limits for specific procedures? Does the Act prohibit limits on the number of visits for a particular condition or procedure?

Effective January 1, 2014, annual and lifetime dollar limits on the ten “essential health benefits” are prohibited. The ten essential health benefits defined in the Act are:

1. ambulatory patient services;
2. emergency services;
3. hospitalization;
4. maternity and newborn care;
5. mental health and substance use disorder services;
6. prescription drugs;
7. rehabilitative services and devices;
8. laboratory services;
9. preventive and wellness services and chronic disease management; and
10. pediatric services.

Day, visit, and frequency limits are not subject to the annual dollar limit rules. However, the Department of Labor (DOL) has advised that these limits must not become de facto annual or lifetime benefit limits.

For example, a limit of 10 doctors visits alone may be acceptable. If the plan also places a limit on how much they’ll pay per visit, say $50, the result would be a de facto $500 annual limit.